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Burn trauma: more than skin deep

Aserious burn is one of the most horrendous traumas the human body can suffer. The damage from burn injuries is often extensive, sometimes leading to permanent impairment. In many cases, physical and psychological consequences last long after the flames go out.

According to the American Burn Association, the US has one of the highest fire death rates in the industrialized world, with more than two million injuries each year. Approximately 70,000 of these require hospitalization, and nearly 20,000 patients are admitted to specialized burn units. As many as 10,000 victims may die from burn-related infections.

The good news is that the incidence and severity of burn injuries have declined significantly over the past 20 years. Advances in resuscitation, wound care, nutritional support, infection control, grafting, and reconstructive surgery have contributed to this progress. And patient survival continues to improve.

Advances in burn care have created a new patient population of "burn survivors." Skin is the largest and most complicated body organ. Continually evolving techniques for wound healing and tissue repair offer patients expanded opportunities for favorable outcomes, often eliminating the need for reconstructive surgery later in the recovery process.

The first great strides were made in getting patients through the initial phase of shock. The swelling and blistering characteristic of burns is caused by fluid loss from damaged blood vessels. It is now apparent that severely burned patients require immediate transfusion of blood or a physiological salt solution to restore fluid levels and maintain blood pressure.

Specialized nutritional support is routinely provided to restore homeostasis. The importance of hydration and monitoring urinary output to assess kidney function has also been established. Aggressive volume resuscitation, protein replacement, and inclusive blood studies have become standard protocol to avoid burn shock.

Another landmark in burn treatment occurred when physicians began debriding or surgically excising as much burned tissue from the site as soon as possible. Meticulous wound care with debridement, whirlpool treatments, topical antibiotics, and frequent dressing changes has been shown to effectively decrease the incidence of infection. The use of systemic antibiotic therapy with penicillin or cephalosporin has also been instituted when indicated to reduce sepsis.

After stabilizing the patient medically and applying aseptic wound management, achieving the next task in nature's process of repair has been formidable - finding a new "second skin" as a first line of defense against infection and dehydration.

"Reconstruction begins during the critical care management phase of acute hospitalization as nurses medically stabilize the patient and work to maintain normal body function," says Robert Dembicki, RN, MS, nurse manager of The New York Firefighter Burn Center at The New York-Presbyterian Hospital, Cornell Campus, NY. Dembicki warns, "Cosmesis cannot be a priority immediately following burn trauma. Our goal is to get burn victims 'over the hump.' We worry about restoring function, preventing infection, and limiting damage to prevent the need for reconstruction later in the course of recovery."

Left alone, the body tries to close wounds quickly by contraction. However, this results in serious scarring that is not only disfiguring, but also disabling. Therefore, skin grafting is generally indicated for serious second- and third-degree burns.

Joints, however, are especially troublesome. "From the moment a patient comes in, we work to maintain range of motion for all involved body parts," says Dembicki. "When an injury involves a burn to the hands, for example, we mold a plastic splint specific to the patient's anatomy, with the hand in extended position to avoid dexterity problems after tissue repair." The recovery and rehabilitation are matters of teamwork. While therapists make the splints, nurses maintain them, monitor extremities for edema, and encourage the use of affected limbs.

"Despite all of your best efforts, however, there are times when scar tissue forms over joints, causing contractures," says Dembicki. Reconstructive surgery is then needed to release these contractures. "Sometimes reconstruction takes place over a course of several years," he adds, "simply because it cannot all be done at one time."

Healthy skin transplanted from another body site is called an autograft. A split-thickness graft takes only the upper skin layer, and the donor site usually heals within several days. The thinner the graft, the faster the donor site heals. Full-thickness grafts usually give a better cosmetic result but sometimes don't adhere and survive.

Although the best wound covering is a patient's skin, the elderly and small people with large burns may not have enough skin available. In these cases, donor sites are limited. Grafting also creates another scar. Dembicki says, "The elderly have thin skin and heal slowly. And some patients cannot tolerate the trauma of a donor site wound. Grafting may not be for everyone."

At the Staten Island University Hospital (SIUH), Laura Giacomoni-Mignola, RN, MSN, CNAA, patient care unit manager of the burn center, notes that good teamwork is essential. "It is most important for patients to receive immediate treatment at the right time by the most qualified staff." Under the direction of burn surgeons, a multidisciplinary staff of primary care nurses, a patient care coordinator, a unit manager, a program manager, and other personnel oversee all aspects of inpatient/outpatient management. This includes coordinated physical care in addition to utilization review, discharge planning, insurance reimbursement, home care, and needs assessment.

"Although cosmesis is important," Giacomoni-Mignola says, "reconstruction to preserve function is the ultimate concern." Nurses work in tandem with physicians, physical therapy, social services, occupational therapy, and dietary throughout the recovery process.

Scar management is one type of reconstructive strategy. After wounds are cleansed, they are usually dressed with special topical agents. Extremities are splinted to maintain alignment. Sicagel applied to the scar area improves skin texture. Garments such as pressure sleeves, stockings, or vests are adjusted over time to reach the desired level of compression.

Some procedures in reconstructive surgery are quite common. Placing wires in the hand of someone whose fingers begin to contract is not unusual. Patients who consistently remove hand splints or refuse to do range-of-motion exercises eventually develop contractures and a claw-like deformity of the hand. It is sometimes necessary to insert wires into the fingers for several weeks to prevent involuntary flexion of finger muscles.

Although contracture releases are common, a variety of factors must be considered. "An elderly person might not be able to tolerate the insult of another surgical procedure," says Dembicki. "What is the best intervention for a patient whose life expectancy is not high? It is not uncommon for elderly patients to die shortly after transition out of hospital."

Giacomoni-Mignola says, "Body disfigurement poses major challenges for patients, their families, and healthcare professionals. Nurses working with burn patients must help them to develop positive beliefs, good communication, and effective coping skills. Building self-confidence and self-esteem is part of effective rehabilitation."

"At SIUH, a team of specialists offers both education and emotional support as part of the recovery process," says Giacomoni-Mignola.

"Effective July 1, we began support groups of burn survivors to allow people to share their experiences and find solutions to specific difficulties.

Most cases are household accidents, such as cooking, candle burns, barbecue grill accidents, knocking over hot coffee, and bathtub burns." Therefore, educational programs are being developed to raise the awareness of burn injuries.

Some persons may consider an injury minor and not seek care. Giacomoni-Mignola describes the case of an 18-month-old child whose hand had been burned with coffee as an infant. Although the parents treated the injury with first aid at that time, they had no idea that there would be any consequences. Recently, the child's hand began to contract and lose function, requiring release of contracture under general surgery.

"Reconstruction in a burn unit means restoration of function and the ability to perform activities of daily living. The reconstructive process begins as soon as the patient is admitted," says Dembicki. "We do not do much in the way of cosmetic surgery. If patients want surgery for aesthetics, they usually pursue that course after discharge."

Unfortunately, there is a limit to what one can accomplish through rehabilitation. Dembicki explains, "We have cooking classes and other exercises to help patients resume activities of daily living before discharge.

Unfortunately, not all patients return to their previous level of functioning. The elderly in particular may not be able to return to independent living even after extensive rehabilitation." For this population, a disabling injury is often double-jeopardy.

"Burn nurses care for patients and families. These injuries are unexpected and create tremendous disruption in the entire support network," says Giacomoni-Mignola. It is critical for everyone to be both hopeful and realistic during the recovery process.